3.1.2 Antimuscarinic bronchodilators

Short-acting muscarinic antagonists (SAMAs)

Ipratropium Bromide
  • Aerosol inhalation 20 micrograms/ metered inhalation (£5.56 = 200 doses)
  • Nebuliser solution 250 micrograms/ml (£2.75 = 20 x 2ml unit dose vials)

Indications

Dose

  • By aerosol inhalation, 20–40 micrograms 3–4 times daily
  • By inhalation of nebulised solution, reversible airways obstruction in chronic obstructive pulmonary disease, 250–500 micrograms 3–4 times daily

Notes

  1. Acute angle glaucoma may occur with ipratropium particularly when used in a nebuliser with salbutamol. Care should be taken to avoid escape from the mask into the eyes.

Long-acting muscarinic antagonists (LAMAs)

Tiotropium
  • Braltus® inhalation powder, capsule (Zonda® device) (£25.50 = 30 days)
  • Respimat® solution for inhalation (£23.00 = 30 days)

Indications

Dose

  • Adult over 18 years:
    • Respimat® Inhalation solution, 5 micrograms once daily (two puffs)
    • Inhalation powder capsule, one capsule once daily (10 micrograms delivered dose)

Notes

  1. The MHRA update below would also apply to tiotropium delivered by the Zonda® device.
  2. MHRA Drug Safety Update (February 2015): When using tiotropium delivered via Respimat® or Handihaler® to treat chronic obstructive pulmonary disease (COPD):
    1. take the risk of cardiovascular side effects into account for patients with conditions that may be affected by the anticholinergic action of tiotropium, including:
      1. myocardial infarction in the last 6 months
      2. unstable or life threatening cardiac arrhythmia
      3. cardiac arrhythmia requiring intervention or a change in drug therapy in the past year
      4. hospitalisation for heart failure (NYHA Class III or IV) within the past year
    2. tell these patients to report any worsening of cardiac symptoms after starting tiotropium; patients with these conditions were excluded from clinical trials of tiotropium, including TIOSPIR
    3. review the treatment of all patients already taking tiotropium as part of the comprehensive management plan to ensure that it remains appropriate for them; regularly review treatment of patients at high risk of cardiovascular events
    4. remind patients not to exceed the recommended once daily dose
Glycopyrronium
  • SeebriBreezehaler® inhalation powder, hard capsule (£27.50 = 30 capsules)

Indications

Dose

  • Adult over 18 years, 50 micrograms (1 capsule) once daily
Aclidinium
  • Eklira Genuair® inhalation powder 375 micrograms (£28.60 = 60 dose unit)

Indications

Dose

  • Adult over 18 years, 1 inhalation twice daily

Notes

  1. There is a lack of robust published evidence comparing aclidinium to other bronchodilators and a lack of good quality long term data on efficacy for aclidinium. Because of this it is recommended that aclidinium is reserved for patients who cannot tolerate the first line LAMAs.

 

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